Healthcare from the perspective of a clinician encompassing both the capture of the clinical viewpoint as well as the technology to help clinicians capture knowledge at the point of care
The thoughts expressed are my own and do not necessarily represent those of Nuance

Monday, October 18, 2010

We are facing significant changes to the world of clinical documentation with the big push encompassed in the Meaningful Use requirements that push provides and healthcare facilities inexorably towards an electronic medical record (EMR) but there remain significant concerns over the potential impact these solutions can and will have on our clinical documentation.

In this piece in the Archives of Internal Medicine (Subscription required):Time Spent on Clinical Documentation: Is Technology a Help or a Hindrance? (abstract) the review of the excessive burden of clerical work was cited as a detractor to the learning process for residents buried in a quagmire of administrative burdens. While the authors acknowledge the value that EHRs bring including more efficient and safer order entry, easily accessible clinical information, and the ability to facilitate documentation through decision support or documentation templates. While these positive effects can streamline and potentially diminish the low value tasks their experience at the University of Chicago demonstrated that

residents often research a new patient extensively on the EHR prior to the history taking and physical examination, preferring to obtain information via clerical work rather than direct patient assessment. In addition, the well-described habits of "cutting and pasting" notes or copying forward previous notes with minor daily updates are work-arounds that may save time but provide little opportunity for education and reflection about a patient's course

Policymakers have been too caught up in discrete data fields, putting the narrative element of the medical transcription process in jeopardy (and) meaningful use rules do not go far enough in guaranteeing that information is robust enough to provide a basis for complex clinical decisions and coordinate patient care. “Granularity and specificity have been overlooked,”

As he point out

It would be unfortunate to sacrifice the nuanced reporting by an overemphasis on discrete data. Structured reporting does not necessarily mean sacrificing the whole, nuanced record

If physicians restrict themselves primarily to structured data entry, what happens to the “nuances of patient variability”

According to the authors nobody has yet attempted to answer this particular question which leaves a major gap in our understanding of the long term impact of the EMR on our clinical knowledge in the context of data, information, knowledge, wisdom (DIKW). And while there are some advantages to the capture of structured data and integration of information from different sources and disparate systems (an important goal in the meaningful use framework) the disadvantages of this limited selection of choices include the increased time to document (= less time with patients or for patients) but more importantly "discrete data may not catch the nuances of patient variability".

The study while limited in size attacks the problem systematically and in sufficient details to arrive at what can only be described as very troubling conclusions. Naturally dictated cardiology notes were manually highlighted with information that would be captured in a a structured data entry system. These annotated notes were then reviewed by two independent physician experts who were asked to review the highlighting of the notes and imagine himself as a physician assuming responsibility for the patient, and to imagine that the highlighting had been added by the previous physician, indicating what he or she believed to be clinically relevant and necessary to include in the communication. In an inspirational piece of design there was no mention of the EMR/EHR and structured note taking so the content was reviewed in pure clinical terms - brilliant! The experts scored missing content that was marked up rating the missing content (if any) in terms of the severity of the omission:
1 - Minimal Severity through to
5 - failing to mark up the language was extremely severe, in terms of having serious consequences for the care of the patient if that clinically relevant information had not been communicated to you

The results, even in the most conservative analysis:

(they) find that 50 percent of the notes include at least one omission rated 3 or higher on a 5-point scale, and 25 percent contain omissions rated 4 or higher

So fully 25% of notes contain omissions that rated 4 or 5 on the severity of the clinical impact of that omission! With less conservative analysis at least one expert showed 100% of notes as containing at least one omission rated with severity of 3 or higher, with 5.25 such omissions on average and omissions with “serious consequences for the care of the patient” (severity rating equal to 5) in fully 55 percent of the notes!
That's worth restating:

All notes contained clinically significant omissions (Grade 3 or higher) and on average contained 5.25 such omissions and over half contained severe omissions!

The content that was missed in some cases could be added to flexible systems but there were distinct pieces of nuanced or detailed elaborations of information and temporal/logical content and the clinician thought process for example:

- after identifying reporting severe pain in one patient’s neck and back, the dictating physician adds that she was “almost brought to tears just in getting her up on the examination table.” Both experts found it relevant that a patient was “able to walk on flat levels and walk at a moderate pace for one hour without abnormal shortness of breath or chest pain.”
- a patient’s nonsustained ventricular tachycardia (fast heart rate) occurred “during post myocardial infarction care…far removed from the time of his infarction.” The cardiologist found it highly relevant, for another patient, that the dictating physician was “hesitant to recommend his FAA certification renewal” without a repeat of a previous catheterization.
- the physician recommends continuing Toprol because it “seems to be controlling [the patient’s] palpitations well.” In another, the dictating physician considers discomfort to be “suggestive of angina.” In a third, the dictating physician expresses a belief that results of stress testing “would rule out significant major coronary artery disease, despite it being a somewhat incomplete study.”

While the study size is small and there are some potential acknowledge bias the design and conservative analysis suggests the problems is very significant and adds further weight when considering the methods for capturing and recoding clinical data. And while it is possible that adding this missing content is possible with the free text fields replete in EMR systems I have heard clinicians say they have modified their patient diagnostic review process to avoid the "other" field specifically to limit the time necessary to type this content into the "other" box. Adding speech recognition technology can decrease the time to populate these boxes but providing a more elegant and integrated solution that allows for capture of the full patient story and clinical history. As the authors conclude:

Even under quite conservative assumptions, we have found that important clinical information, detail, and nuance would fail to be captured by an EHR standard’s discrete fields, with potentially serious consequences for the patient. Such omissions could potentially influence not only clinical care, but the progression from data to information to knowledge discovery in clinical research. Clearly the question merits further attention and study.

In the inimitable words from Master Po in the iconic 70s TV Series Kung Fu:

Tread lightly grasshopper

The narrative must be integrated and preserved and will remain a fundamental foundation of clinical knowledge now and into the future of healthcare information systems. How are you preserving the information in your EMR or have you seen the record dumbed down?

On the list of snake oil challenges is the vaccine causes autism bunkum. Unsupported in any scientific study but perpetuated by a wide range of people who may have good intentions but are using their influence to damage years of hard work building vaccination programs and relegating serious and life threatening diseases to the history books

Let's hope the Supreme court can take account of these effects as they consider this case. If not we could be in for a rash of diseases.

Thursday, October 14, 2010

In a timely piece from the NY Times featuring Dr Verghese who continues to demo strategy and teach medical students that the physical examination is an essential part of the clinician patient interaction.

At Stanford, Dr. Abraham Verghese on a mission to bring back something he considers a lost art: the physical exam.<<<<<<<http://nyti.ms/9pqWHCIn what seems much like the House brilliance of observation combined with a ready wit and and extensive knowledge of medicine Dr. Abraham Verghese vividly demonstrates the value and contribution of the physical examination and worries that the skill is being lost in American medicine and is not being taught to medical students in the US. The physical exam should not be relegated to history books and while time pressures make spending time on this intimate interaction difficult the rewards are not just found in more clinical information but also closer links to patients.

Interestingly the article suggests that EHR's "can reduce the time it takes physicians to document patient encounters" but there is a fair amount of research suggesting that EHR can increase the burden and time taken to document. A study in the Healthcare Ledger in March 2009 showed an increase of ~ 4x when documenting using the EHR and there is increasing concern that the current burden of clerical work being required of medical residents is limiting the educational opportunities and failing to teach our future doctors the process of reflection and distillation of a patient history that is an essential part of the diagnostic process (Doll and Arora 2010). Add to that that many EHR systems limit the potential for capturing the complete clinical story of the patient as outlined in a recent study “Communication of Clinically Relevant Information in Electronic Health Records: A Comparison between Structured Data and Unrestricted Physician Language” (Resnik, Niv et al 2010) in a systematic comparison between free natural language dictations and information codified by structured categories in an EHR demonstrated a failure to capture clinically significant information. Even in the most conservative estimate the study demonstrated 25% clinical omissions that rated 4-5 on a 1–5 scale of seriousness (1 being minimal severity and 5 meaning severe).

However the access to real time information and improved legibility deliver significant benefits and advances into our healthcare system. But as Nina Youngstrom points out:

CMS and Medicare contractors are wary of classic EHR physician documentation shortcuts — cloning (cut and paste), macros and templates — and audits are bearing out their concerns

As the audit demonstrated "Each note should contain individualized data that supports the medical necessity of the visit or procedure.” and problems stem from EHR documentation shortcuts:

Cloning (cutting and pasting): Physicians copy information from previous patient encounters (e.g., demographic, history of present illness, exam, medical decision making) and paste it in the current encounter.

Templates: Physicians fill out templates for patient encounters that cover a lot of ground with a few key strokes. The review of systems is pre-filled with the term “negative” for each organ system. For positive answers, physicians must change “negative” to reflect the positive response given by the patient.

Macros: Macros are a type of EHR shortcut that allows the entry of generous customized data quickly. Though initially CMS resisted the use of macros, the agency gave its approval for their use by teaching physicians (see Medicare Transmittal 811). With macros, teaching physicians, for instance, type in “.liv” to convey “liver exam,” which triggers a drop-down menu of choices for the next step.

So avoiding these pitfalls and capturing the essence of the clinical consultation in the "Medical decision making" which is the cognitive process and is hard to document with templates and macros is key to both good quality documentation as well as avoiding potential CMS audits and challenges in the future.

There is no one size fits all to these challenges and in different clinical circumstances different solutions will be beneficial but providing tools to document the complete narrative and extract key data elements will help drive clinically actionable data into the EHR while maintaining the decision making process that includes taking and documenting a full history without burdening the physician with mundane data entry tasks. Clinical Language Understanding offers to bridge this divide capturing the voice with proven voice recognition Technology (Dragon Medical) and the exciting addition of Clinical Language Understanding: The video demonstrates the CLU in action offering an alternative path for clinicians weary from screen based data entry:

and read about the collaboration with IBM here. What would you rather be doing? Manual data entry or dictating. This announcement and the work underway offers a solution that bridges the divide between the need for clinically actionable data and physicians desire to capture the complete clinical story for the patient.